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Treating Blood ..

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Hypertension is a primary, modifiable risk factor for stroke and decreasing blood pressure (BP) can reduce the risk of stroke by up to 40%.1,2 Achieving a blood pressure goal of <140/90, or less depending on a patient’s co-morbid disease states, is recommended to help prevent an initial ischemic stroke from occurring.1 Following an ischemic stroke, current guidelines continue to recommend a reduction in BP; however, it is presently unknown what the optimal BP target following a stroke should be. It is also unclear how the timing of BP reduction, antihypertensive medications used, or quantity of BP reduction may affect outcomes.2 Current hypertension recommendations for post-ischemic stroke are vague, indicating that a BP reduction of 10/5 mmHg may be beneficial and define a normal BP of <120/80 mmHg.2

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Ovbiagele and colleagues conducted a post hoc observational analysis, of the Prevention Regimen for Effectively Avoiding Second Strokes (PROFESS) trial, to assess the association between systolic blood pressure (SBP) level and risk of recurrent stroke in patients with a recent non-cardioembolic ischemic stroke. A recent stroke was defined as a new focal neurological deficit of cardiovascular origin lasting for more than 24 hours occurring within 120 days of randomization. In the PROFESS trial, patients were randomized to receive aspirin/extended-release dipyridamole or clopidogrel and telmisartan or placebo. Patients could also receive additional medications for BP control at the clinician’s discretion. Patients were categorized by their average SBP as very low-normal (<120 mmHg), low-normal (120-129 mmHg), high-normal (130-139 mmHg), high (140-149 mmHg), and very high (≥150 mmHg). The high-normal (130-139 mmHg) category was used as the reference for comparison. The primary outcome was recurrence of any type of stroke and the secondary outcome was a composite of stroke, myocardial infarction, or death from any vascular cause. No significant differences between groups were found in the PROFESS trial; therefore, all patients were included in this post hoc analysis of BP control and risk of recurrent stroke.3

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A total of 20,330 patients who were well matched at baseline were assessed. However, a diagnosis of hypertension, diabetes, and use of antihypertensive medications occurred at a higher incidence as SBP category increased. Compared to the high-normal group (6.8%), rates of recurrent stroke were significantly higher for the very low-normal (8%, adjusted HR 1.29), high (8.7%, adjusted HR 1.23) and very high (14%, adjusted HR 2.08) SBP groups, demonstrating a J-shaped effect. In addition, the risk of secondary outcomes was greater for the very low-normal (adjusted HR 1.31), low-normal (adjusted HR 1.16), high (adjusted HR 1.24), and very high (adjusted HR 1.94) SBP groups compared to the high-normal group. The investigators also analyzed the timeframe associated with these findings, and found that the association between outcomes and SBP category were most pronounced during the first 6 months following the stroke. The authors concluded that their results are hypothesis generating and BP targets after an ischemic stroke must continue to be investigated, but achieving a BP goal of <140/90 following an ischemic stroke is supported by these results.3

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This study found a J-shaped association between SBP (SBP <120 and ≥140 mmHg) and an increased risk of recurrent stroke particularly within 6 months of the initial stroke, and suggests that conservative BP control following a non-cardioembolic ischemic stroke may be desired. The study did not include patients whose stroke was cardioembolic in nature, limiting the generalizability of these findings.3 This study was a post-hoc analysis of the PROFESS trial, and further study is needed to fully clarify the optimal post stroke blood pressure target, and what is the time period, post stroke, for when the benefits of that target remain.

1. Goldsteine LB, Bushnell CD, Adams RJ, et al. Guidelines for the Primary Prevention of Stroke: A guideline for the healthcare professional from the American Heart Association/American Stroke Association. Stroke 2011;42:517-84. Epub 2010 December 2.   [PubMed: 21127304]
2. Furie KL, Kasner SE, Adams RJ, et al. Guidelines ...

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